MEDICARE: ELIJAH COLE STEVENSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1942991203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIJAH COLE STEVENSON

Provider Business Mailing Address
First Line	:	5165 LANGSTON RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5547
Country	:	US
Telephone Number	:	757-472-1425
Fax Number	:

Provider Business Practice Location Address
First Line	:	5165 LANGSTON RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5547
Country	:	US
Telephone Number	:	757-472-1425
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2023
Last Update Date	:	05/17/2023

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